Healthcare Provider Details

I. General information

NPI: 1972576007
Provider Name (Legal Business Name): ANDREW MAZUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 ALLENS AVE STE 110
PROVIDENCE RI
02905-5443
US

IV. Provider business mailing address

765 ALLENS AVE STE 104
PROVIDENCE RI
02905-5443
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-6800
  • Fax: 401-432-6832
Mailing address:
  • Phone: 401-606-4150
  • Fax: 401-270-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number150693
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD09581
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: